Insomnia

Insomnia is often caused by another disease or psychological problem. In any such case, it is important that the underlying condition be treated to eradicate the insomnia. A psychologist or psychiatrist may be able to determine if psychological issues are causing the insomnia. A physical examination may help determine if the insomnia is caused by other health issues. Recent research has reported that cognitive behavior therapy can be more effective than medication in controlling insomnia. In this therapy, patients are taught improved sleep habits and are counseled on counter-productive thoughts about sleep. For success with this type of therapy, the individual may need to see a therapist weekly over two to three months.

The U.S. Food and Drug Administration (FDA) has issued warnings for all sedative-hypnotic drugs used for sleep regarding the potential for adverse events. Anaphylaxis and severe facial angioedema (swelling) can occur the first time a sleep product is taken. Complex sleep-related behaviors may include sleep-driving (driving while not fully awake, and with no memory of driving), making phone calls, and preparing and eating food while asleep.

Benzodiazepines: Benzodiazepines are a class of sedative/hypnotic drugs that were once the standard therapy for insomnia. The benzodiazepines used for insomnia include temazepam (Restoril®), flurazepam (Dalmane®), estazolam (ProSom®), and triazolam (Halcion®). Benzodiazepines have the potential of causing psychological and physical dependence. Physical withdrawal symptoms may occur if the drug is not carefully tapered following long-term use. Most common side effects of benzodiazepines include drowsiness, impaired coordination, fatigue, confusion and disorientation, dizziness, decreased concentration, short-term memory problems, dry mouth, blurred vision, and irregular heart beat. Benzodiazepines may cause depletion of the natural hormone melatonin from the body. Melatonin helps the body regulate sleep/wake cycles and circadian rhythm.

Non-benzodiazepines: In recent years, a newer class of sedative hypnotic medications has been developed, often termed the non-benzodiazepine, benzodiazepine receptor agonists. These newer medications appear to have better safety profiles and less adverse effects than the benzodiazepines. They are also associated with a lower risk of abuse and dependence than the benzodiazepines, although abuse and dependence do occur. Examples of medications in this class include zolpidem (Ambien®), zaleplon (Sonata®), and eszopiclone (Lunesta®).

Zolpidem (Ambien®, Ambien CR®) may help the individual have a more restful sleep and stay asleep longer. It is typically prescribed for administration at bedtime and may be used when the individual has trouble falling asleep and/or staying asleep. Zaleplon (Sonata®) is generally used in individuals who have trouble falling asleep. It is often taken at bedtime or later, such as when awakening during the night, as long as there are at least four or more hours left to sleep. Eszopiclone (Lunesta®) helps people get to sleep faster and also appears to help the individual stay asleep through the night. The FDA has approved Eszopiclone for patients who have difficulty falling asleep, as well as those who are unable to sleep through the night. Eszopiclone must be taken immediately before bedtime and the individual should make sure that he or she has a full eight hours devoted to sleeping before taking it. As with the other medications, side effects can occur, including daytime drowsiness, dry mouth, and dizziness. Unlike the other medications in this class which are recommended only for use on a temporary basis, Eszopiclone is approved for longer term use (longer than seven days).

Melatonin agonists: Ramelteon (Rozerem®) belongs to a new class of drugs called melatonin agonists. Melatonin is a hormone produced by the pineal gland (located in the brain) during the dark hours of the day-night cycle, also known as the circadian rhythm. Melatonin levels in the body are low during daylight hours. The pineal gland responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. Ramelteon promotes the onset of sleep by increasing levels of the natural hormone melatonin, which helps normalize normal circadian rhythm and sleep/wake cycles. Ramelteon is approved by the U.S. Food and Drug Administration (FDA) for insomnia characterized by difficulty falling asleep. These drugs have a relatively mild side effect profile, a lower likelihood of causing morning sedation, and may lack the potential for abuse and dependence. The body regulates back to normal daytime levels of melatonin when it is daylight. Side-effects may include daytime sleepiness, dizziness, and fatigue.

Antidepressants: The sedating antidepressant medications most commonly used to help with sleep include trazodone (Desyrel®), amitriptyline (Elavil®), and doxepin (Sinequan®). When used for sleep, these medicines are used in lower doses than when used in the treatment of depression. Benefits of these antidepressants include a lack of addictive properties or tolerance and the added benefit of providing some analgesic (pain relieving) benefit. Side effects include dry mouth, blurred vision, a "hangover" in the morning, constipation, urinary retention, and nausea.

Over The Counter (OTC) sleep aids: Antihistamines may be used short-term for insomnia. Diphenhydramine (Benadryl®) is the most commonly used OTC antihistamine sleep aid, and can be purchased alone (Benadryl®, Nytol®, Sominex®) or in combination with other OTC items such as acetaminophen (Tylenol PM®). Combining diphenhydramine with acetaminophen has the added benefits of not only helping the individual sleep better, but providing pain relief also. OTC sleep aids are not intended for long term use, because dependency can develop. Diphenhydramine can cause sedation, dry mouth, and constipation. In the elderly, diphenhydramine can cause confusion and oversedation. Also, many OTC products contain the same ingredients, such as acetaminophen which can be purchased in many combinations. Tylenol® and Tylenol PM® both contain acetaminophen and should not be taken together. Acetaminphen has been reported to cause severe liver damage in overdose. It is recommended by healthcare professionals to not take more than four grams of acetaminophen daily.

Atypical antipsychotic drugs: Other medications used off-label for insomnia are low doses of the atypical antipsychotics, including quetiapine (Seroquel®), mirtazapine (Remeron®), and olanzapine (Zyprexa®). Antipsychotics appear to work by blocking the action of the neurotransmitters serotonin and dopamine, thus producing a tranquilizing, sedating, and antipsychotic effect. Atypical antipsychotics may increase the incidence of extrapyramidal side effects (abnormal movements, muscle stiffness/shaking, or an uncomfortable restless feeling) and weight gain in higher doses. More serious side effects may include diabetes and high cholesterol and triglycerides.

Others: Requip® (ropinirol) may be used if restless leg syndrome (RLS) is present. Restless legs syndrome (RLS) causes a powerful urge to move the legs. The legs become uncomfortable when lying down or sitting. Some people describe it as a creeping, crawling, tingling or burning sensation. Moving makes the legs feel better, but not for long. RLS occurring at night can disrupt sleeping patterns and cause insomnia. Common side effects associated with Requip® include nausea, drowsiness, vomiting, and dizziness.

Strong scientific evidence :

Melatonin: The natural hormone known as melatonin helps to regulate sleep/wake cycles (circadian rhythm). Certain diseases such as cancer, prescription medications such as benzodiazepines, and age may decrease melatonin levels. Several human trials suggest that melatonin taken by mouth, started on the day of travel (close to the target bedtime at the destination) and continued for several days helps with symptoms of jet lag such as reducing the number of days required to establish a normal sleep pattern, diminishing the time it takes to fall asleep ("sleep latency"), improving alertness, and reducing daytime fatigue.

Although these results are compelling, the majority of studies have had problems with their designs and reporting, and some trials have not found benefits. Overall, the scientific evidence does suggest benefits of melatonin in up to half of people who take it for jet-lag. More trials are needed to confirm these findings, to determine optimal dosing, and to evaluate use in combination with prescription sleep aids.

Caution is advised when taking melatonin supplements, as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Melatonin should not be used long-term (nightly for more than four weeks).

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Melatonin: Melatonin has been studied for delayed sleep phase syndrome (DSPS), insomnia in the elderly, sleep disturbances in children with neuro-psychiatric disorders, and sleep enhancement in healthy individuals. Multiple human studies have measured the effects of melatonin supplements on sleep in healthy patients. Melatonin is often taken by mouth, 30 to 60 minutes prior to sleep time. Most trials have been small, brief in duration, and have not been rigorously designed or reported. However, the weight of scientific evidence does suggest that melatonin decreases the time it takes to fall asleep ("sleep latency"), increases the feeling of "sleepiness," and may increase the duration of sleep.

Music therapy: Music is used to influence physical, emotional, cognitive and social well-being, and improve quality of life for healthy people, as well as those who are disabled or ill. It may involve either listening to or performing music, with or without the presence of a music therapist. In older adults music may result in significantly better sleep quality as well as longer sleep duration, greater sleep efficiency, shorter time needed to fall asleep, less sleep disturbance and less daytime dysfunction. There is also evidence of benefit in elementary age children who use music during naptime and bedtime.

Valerian: Valerian root (Valerian officinalis) has been used as a sedative and anti-anxiety treatment for more than 2,000 years. Several studies in adults suggest that valerian may improve the quality of sleep and reduce the time to fall asleep (sleep latency), for up to four to six weeks. Ongoing nightly use may be more effective than single-dose use, with effects increasing and then leveling out over the first four weeks of use. Better effects have been found in poor sleepers. However, most studies have not used scientific ways of measuring sleep improvements, such as sleep pattern data in a sleep laboratory. Caution is advised when taking valerian supplements, as numerous adverse effects including drowsiness and drug interactions are possible. Caution is also advised when operating heavy machinery or an automobile if taking valerian supplements. Valerian is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

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5-HTP (5-hydroxytryptophan): 5-HTP is the precursor of the neurotransmitter serotonin. It is obtained commercially from the seeds of the plant Griffonia simplicifolia. Although many naturopathic regimens for sleep include 5-HTP, there is insufficient evidence in its use for sleep disorders or insomnia. Additional studies are needed before a conclusion can be drawn. 5-HTP may cause drug interaction with medications such as antidepressants and sleep medicines. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Acupressure, Shiatsu: Shiatsu literally means finger (Shi) pressure (Atsu) in Japanese. Shiatsu technique involves finger pressure at acupoints and along body meridians (divisions). It can incorporate palm pressure, stretching, massaging and other manual techniques. Preliminary research supports the use of acupressure for improving sleep quality in elderly patients and possibly in healthy adults of all ages. Better-designed trials are needed to support these results. A small study reports that acupressure may also provide early prevention and treatment for sleep apnea, a common cause of insomnia.

Acupuncture: The practice of acupuncture, or the insertion of needles, originated in China 5,000 years ago. Traditional Chinese medicine commonly uses acupuncture to treat insomnia. A review of the available studies found reports of benefit, but major weaknesses in the design of the research makes the evidence insufficient for or against acupuncture for insomnia.

Aromatherapy: Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. The oils are applied to the skin, sprayed in the air, or inhaled. Based on human use, lavender and chamomile aromatherapy are thought to be effective sleep-aids. Although preliminary small studies suggest some hypnotic effects, there have been no well-designed human trials. Further research is needed. Do not use essential oils (aromatherapy) internally.

Ayurveda: Ayurveda, which originated in ancient India over 5,000 years ago, is probably the world's oldest system of natural medicine. There is evidence from one well-designed study that a traditional Ayurvedic formula (Blissful Sleep®, Maharishi Ayurvedic Products International) containing valerian (Valeriana wallichi), rose petals (Rosa centifolia), muskroot (Nardostachys jatamansi), heart-leaved moonseed (Tinospora cordifolia), winter cherry (Withania somnifera), pepper (Piper nigrum), ginger (Zingibar officinalis), aloeweed (Convolvulus pluricalis), and licorice root (Glycyrrhiza glabra) may decrease sleep latency (time needed to get to sleep) in people with sleep-onset insomnia, with no side effects. Further research is needed to confirm these results.

Chamomile: Chamomile (Matricaria recutita) has been used medicinally for thousands of years, and is widely used in Europe. Traditionally, chamomile preparations, such as tea and essential oil aromatherapy, have been used for insomnia and sedation (calming effects). Better research is needed. Chamomile is not recommended for individuals allergic to flowers in the daisy family, or during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Chiropractic: Chiropractic healthcare is a discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. The broad term "spinal manipulative therapy" incorporates all types of manual techniques, including chiropractic. Although physical manipulation is used traditionally for jet lag, there is not enough reliable scientific evidence.

Guided imagery: Therapeutic guided imagery uses the power of the imagination as a healing tool. Guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Early research supports the value of combined pharmacotherapy and relaxation training in the treatment of insomnia. Further research is necessary.

Hops: Animal studies and traditional uses of hops include insomnia, sedation, and alcoholic beverage production. Hops may have sedative and sleep-enhancing (hypnotic) effects. However, little human research has evaluated the effects of hops on sleep quality. Further study is needed in this area. Hops may cause drowsiness, so caution is used when operating an automobile or heavy machinery. Hops supplements are not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.

Hypnotherapy: Hypnotherapy or hypnosis uses the power of suggestion to help individuals overcome all types of adversity, including health issues such as insomnia. Several early studies report that hypnosis may decrease the amount of time it takes to fall asleep, increase the duration of sleep, and improve sleep quality. However, this research is not well designed or reported, and cannot be considered definitive.

Kundalini yoga: Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. One small study suggests improved sleep quality with the help of a regime of Kundalini yoga practices. However, there is insufficient evidence for or against this intervention for insomnia.

Lavender: Lavender aromatherapy is often promoted as a sleep aid. Although early evidence suggests possible benefits, more research is needed before a firm conclusion can be drawn.

Lemon balm: Lemon balm (Melissa officinalis) is a commonly used herb with a lemon like smell. High-quality clinical evidence supporting the use of lemon balm as a sedative/hypnotic is lacking, although it has been used with positive results with valerian for sleep. Rigorous clinical studies are required to better support the use of lemon balm as a sedative/hypnotic.

Melatonin: There is limited consistent evidence on the effectiveness of melatonin given to patients with sleep disturbances associated with bipolar disorder (such as insomnia or irregular sleep patterns), blind patients with circadian rhythm disturbances, patients with depression who have REM latency sleep abnormalities, elderly patients with insomnia of unknown origin, patients with REM sleep behavior disorder, or patients with work shift sleep disorder. Further research is needed in these areas before a clear conclusion can be reached.

Additionally, several published cases report improvements in sleep patterns in young people with damage to the pineal gland area of the brain due to tumors or surgery. Due to the rarity of such disorders, controlled trials may not be possible. Consideration of melatonin in such patients should be under the direction of a qualified healthcare provider.

Relaxation therapy: Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. Several human trials suggest that relaxation techniques may be beneficial in people with insomnia, although effects appear to be short-lived. Research suggests that relaxation techniques may produce improvements in some aspects of sleep such as sleep latency and time awake after sleep onset. Better research is necessary before a firm conclusion can be drawn.

Yoga: Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Preliminary research reports that yoga may benefit sleep efficiency, total sleep time, number of awakenings, and quality of sleep. Well-designed research is necessary before a firm recommendation can be made.

Fair negative scientific evidence :

Vitamin B12: Taking vitamin B12 orally, in methylcobalamin form, with or without bright light therapy, does not seem to be effective for treating primary circadian rhythm sleep disorders. Additional research would help to confirm these results.

Exercise: Exercise regularly, at least 30 minutes daily, five days a week. Aerobic exercise and general fitness are important in maintaining good health and preventing insomnia. Exercising within two hours of bedtime may cause trouble falling asleep.

Diet: Avoid large meals and excessive fluids before bedtime, as they can cause trouble falling asleep. Healthcare professionals recommend avoiding caffeine, nicotine, beer, wine and liquor six to eight hours before bedtime. Caffeine and nicotine are stimulants to the nervous system and may cause insomnia. Alcohol interferes with normal sleep patterns by disrupting neurotransmitters (nerve chemicals) in the brain that control or regulate sleep. When these neurotransmitters (including dopamine and serotonin) are disrupted, disturbances, such as insomnia, can result. Small amounts of alcohol can cause early sedation or sleepiness, and is often used as a sedative. However, the use of alcohol as an effective sedative can be extremely misleading because the side effects that can result are usually even more harmful and detrimental to the natural sleep cycle. Alcohol can also be associated with sleep apnea.

Environment: Controlling the environment, such as light, noise, and temperature, may help prevent insomnia. Night shift workers especially must address these factors.

Going to bed at the same time daily helps develop the natural circadian rhythm cycle and the sleep/wake cycle.

Other: In order to prevent insomnia, healthcare professionals recommend to establish a regular bedtime, use the bedroom for bedroom activities only, avoid staying in bed for long periods of time while awake, or going to bed because of boredom, take the TV or computer out of the bedroom (too much stimulation), relax by reading, taking a bath, or listening to soothing music before getting to bed, and try to avoid emotional upset or stressful situations prior to bedtime.

Infants and children: To help infants and children avoid insomnia, healthcare professionals recommend for the parent to avoid being readily available to a child during the night. Otherwise, the child may become dependent on attention and become sleepless if deprived of it. For children who have trouble falling asleep, try to make sure that the child is not disturbed by unnecessary noise. Leaving a radio playing soft music may help cover up disturbing noises. Avoid sending a child to bed as punishment, that can result in poor sleep caused by fear, and never give a child sleeping medicine without consulting a doctor first.